A non-healing tongue ulcer: what to do at the first visit
A 61-year-old woman attends with an ulcer on the left lateral border of the tongue that has been present for three weeks. It is 15 mm across, has rolled, indurated margins and a granular floor, and feels fixed to the underlying tissue. It is only mildly uncomfortable. She smokes 20 cigarettes daily and drinks about 25 units of alcohol a week. She has a sharp lower left molar that she says 'catches' the area; two weeks ago another dentist smoothed it and told her to return if it had not settled. There is no cervical lymphadenopathy. She has no history of previous ulceration and has lost 4 kg without trying.
1. Give your differential diagnosis and the features that support each possibility.
Read the worked answer
1. Squamous cell carcinoma - the diagnosis you must exclude first Supported by: age over 60; lateral tongue, the commonest intraoral site; three weeks' duration (beyond the 2-3 week threshold for 'non-healing'); induration and rolled margins - induration is the single most useful clinical sign of malignancy and is not a feature of traumatic or aphthous ulceration; fixation to deep tissue implies invasion; heavy smoking plus high alcohol intake are multiplicative risk factors; unintentional 4 kg weight loss; and failure to resolve despite removal of the apparent cause.
2. Chronic traumatic ulceration Supported by the sharp molar. Against: a purely traumatic ulcer should show a clean response within 1-2 weeks of removing the cause, it is usually less indurated, and removal of the cause has already been attempted. A traumatic ulcer is a diagnosis of exclusion made in retrospect - do not use the sharp tooth as an explanation for an indurated 15 mm ulcer.
3. Other malignancy or a metastatic deposit - lymphoma, salivary gland malignancy; less likely but not excluded by appearance.
4. Chronic hyperplastic candidosis, tuberculosis, syphilis, or a drug-related ulcer - possible but none fits as well; syphilis gives a different morphology, and there is no relevant history.
5. Major aphthous ulceration - usually painful out of proportion and recurrent; she has no previous ulceration.
What is not on the list: 'just a traumatic ulcer, review in two weeks'. The combination of induration, fixation, duration, weight loss and risk factors makes observation indefensible.
2. What is your immediate management, and why would biopsying the lesion yourself in primary care be the wrong move?
Read the worked answer
Immediate management
- Urgent referral on the suspected cancer pathway (two-week wait) to the local oral and maxillofacial or head and neck surgery service - today, not at the end of a course of treatment. State 'suspicious of oral malignancy' explicitly on the referral, with the specific features: site, size, duration, induration, fixation, risk factors and weight loss. Vague referrals get triaged down.
- Do not prescribe a two-week trial of antifungal, antiseptic or steroid therapy as a diagnostic test. It delays referral and a partial response can falsely reassure.
- Do not biopsy in primary care. A small incisional biopsy from the edge of an indurated lesion can miss the invasive focus, may seed tumour, and produces a false-negative that is far worse than no biopsy. Referral centres take the biopsy with staging in mind.
- Do address the sharp tooth - smooth or remove any genuine source of trauma and record that you did so - but do not make resolution of the tooth the condition of the referral. Note in the record that the referral was made despite removing the irritant.
- Photograph the lesion if you have the facility, with consent, and record the clinical description precisely in the notes; a dated record of size and appearance is valuable at the next visit.
- Ask about hoarseness, dysphagia, otalgia and any neck lump, and examine the neck yourself. If any are present, telephone the on-call service rather than relying on a routine two-week pathway.
Safety net: tell her clearly why she is being referred urgently, what will happen, and that she must return if she has not been contacted within a few days. Give the reason in plain words - 'this needs checking for cancer' - rather than a euphemism that she may not act on.
3. She asks whether her smoking and drinking are relevant, and says she has smoked for 40 years so 'it makes no difference now'. How do you respond, and what does this mean for the rest of your care?
Read the worked answer
The honest answer Smoking and alcohol act synergistically on oral mucosa - the combined risk is greater than the sum of the individual risks - and she should be told this plainly, but not with blame. The relevant clinical point is that stopping now still has value: mucosal field change is dose- and time-dependent, and cessation improves outcomes after treatment, reduces recurrence and second primary rates, and improves wound healing and radiotherapy tolerance if treatment is needed. 'Forty years' is a reason to act, not a reason not to.
Do it concretely
- Offer referral to a stop-smoking service with a named contact rather than generic advice; brief advice plus referral is what changes behaviour, and 30 seconds of it is legitimate clinical care.
- Take an alcohol history in units and give it a number, with the same referral route if she is willing.
- Record both in the notes, and record that the advice was given. If she declines, that is her decision - document it and continue to provide care without moralising.
Implications for the rest of your care
- She is at high risk of further lesions, so she needs a structured oral mucosa examination at every visit, with a written record of the site and size of anything found - the earlier you detect a second lesion, the better.
- She has lost 4 kg without trying: that is a red flag that belongs in the referral regardless of the oral findings.
- Her dental care continues: do not let a cancer referral stall routine prevention, but avoid elective complex work until the diagnosis is known - the treatment plan for the rest of the mouth may change completely, and she may not be able to attend.